Guttate Psoriasis: Causes, Symptoms, and Treatment Options

‍Psoriasis is a chronic autoimmune condition that causes inflammation in the skin. Psoriasis causes uncomfortable rashes that are not just unpleasant, but can also be embarrassing and painful. 

Different types of psoriasis can cause different types of rashes, but they all result from autoimmune inflammation in the skin.

Guttate psoriasis is a variant of psoriasis that typically appears after a streptococcal infection and is characterized by small, drop-like lesions. It is more common in children and adolescents than in adults and accounts for less than 30% of all psoriasis cases. 

Although it is often self-resolving, guttate psoriasis can become chronic plaque psoriasis.

This article will discuss the pathology and the symptoms of guttate psoriasis and discuss effective, research-backed strategies to promote healing from guttate psoriasis. 

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What is Guttate Psoriasis?

Guttate psoriasis, the second most common form of psoriasis in children after plaque psoriasis, is a distinct form of psoriasis that commonly arises after streptococcal infections as well by viral infections including rhinovirus and COVID-19, and fungal infections like Candida albicans.

It is more prevalent in children and adolescents. Guttate psoriasis is characterized by multiple small, drop-like lesions on the trunk, arms and legs that typically resolve with treatments, or on their own, within a few weeks to months. 

While guttate psoriasis has a favorable prognosis characterized by rapid resolution and extended remission periods compared to other psoriasis types, between 40% and 68% of cases may progress to chronic plaque psoriasis (the most common form of psoriasis). 

Guttate psoriasis is often diagnosed based on clinical history and presentation, with a skin biopsy rarely needed. Treatment primarily involves topical corticosteroids and phototherapy, with broadband UVB being particularly effective.

Who is Affected?

Guttate psoriasis most commonly affects children and adolescents. It affects both males and females equally, without a strong gender preference.

Understanding the Condition

Guttate psoriasis is typically triggered by a viral or bacterial infection. Pharyngeal or perianal streptococcal infections are most associated with guttate psoriasis, although viral infections including COVID-19 and some fungal infections have also been known to cause this condition. 

Genetically predisposed individuals who get sick can experience immune dysregulation following the infection and develop guttate psoriasis, typically 1-2 weeks after the initial infection, although some sources report that as many as 4 weeks may pass before symptoms arise.

Overactivation of the innate and adaptive immune systems (the two main branches of the immune system) from the infection causes the characteristic teardrop lesions of guttate psoriasis. 

Susceptible people may lack the ability to appropriately modulate the immune response with anti-inflammatory chemicals. 

Guttate Psoriasis vs. Plaque Psoriasis

Guttate psoriasis and plaque psoriasis are both chronic inflammatory skin diseases influenced by immune responses, but their progression and severity differ. 

Guttate psoriasis often resolves faster and has a longer remission period, while plaque psoriasis is more persistent. However, as many as 68% of guttate psoriasis cases evolve into chronic plaque psoriasis.

Guttate psoriasis often begins as small, red, drop-like spots on the skin. In some cases, these lesions persist and gradually merge to form the larger, thicker plaques seen in plaque psoriasis. 

Repeated episodes of guttate psoriasis, commonly triggered by infections like strep throat, can lead to chronic inflammation which makes the skin more prone to developing persistent plaques. Continuous immune activation supports this transition. 

Genetic predisposition such as the presence of the HLA-Cw6 allele can further drive the progression from guttate to plaque psoriasis. Environmental factors like stress, smoking, and obesity may also be involved, as they are linked with the development of plaque psoriasis. 

Inadequate treatment or management of guttate psoriasis may also contribute to the development of plaque psoriasis by allowing ongoing inflammation and skin changes.

Causes and Triggers of Guttate Psoriasis

Genetic susceptibility and certain infections are the most commonly-recognized triggers of guttate psoriasis.

Streptococcal and Other Infections

Streptococcal infections including strep throat, upper respiratory or perianal streptococcal infections, are common triggers for guttate psoriasis outbreaks. 

Streptococcal “superantigens” can over-stimulate the immune system, leading to the rapid onset of small, scaly lesions characteristic of this psoriasis type.

Some viral and fungal infections have also been associated with developing guttate and plaque psoriasis.

Genetic Predisposition

The HLA-Cw6 allele is linked to guttate psoriasis and to stress, obesity, and throat infections.

This allele is strongly associated with more severe and early-onset psoriasis. It is present in 100% of patients with guttate psoriasis, highlighting a strong genetic component.

Immune System Response

The immune system in susceptible individuals can overreact to some infections, causing overstimulation of both the innate and adaptive immune systems that involves cytokines, interleukins, and T cells. 

This leads to the development of guttate psoriasis, or small drop-like psoriatic lesions on the trunk, arms and legs of the affected person, after the initial infection.

Environmental Factors

Stress, obesity, smoking and alcohol consumption have all been associated with the development of guttate psoriasis. 

Skin injuries (the Koebner phenomenon) have also been implicated in the development of guttate psoriasis. Additionally, TNF-alpha inhibitors have been associated with guttate psoriasis.  

Symptoms of Guttate Psoriasis

The appearance of small, drop-like psoriatic lesions on the trunk and limbs following an infection points to guttate psoriasis.

Appearance of Lesions

Guttate psoriasis is characterized by the sudden appearance of thickened, red or dark teardrop-shaped spots covered in silver to gray scales. 

These lesions are typically 2-6 millimeters and up to a centimeter in size and are most commonly found on the trunk, arms, and legs. However, they may also appear in areas of recent injury or trauma (Koebner phenomenon).

The coloring of the lesions differs based on skin tone: red or pink with silvery scales on fair skin, salmon-colored with silvery scales on olive or brown skin, and violet with gray scales or dark brown patches on darker skin tones.

Scaling and Redness

The lesions often have a fine scaling that gives them a rough texture. This scaling may vary in thickness, but it usually appears as a thin, silvery-white or gray layer that covers the darker, thickened spots.

Removing the layer of scales causes pinpoint bleeding (Auspitz sign). 

Itching and Discomfort

The lesions associated with guttate psoriasis can cause itching and discomfort. While some individuals may experience mild irritation, others might suffer from more intense itching, leading to scratching and potential secondary infections.

Distribution of Lesions

Guttate psoriasis commonly affects the trunk, arms, and legs. In some cases, lesions can also appear on the face and scalp. The widespread distribution is a key feature that differentiates guttate psoriasis from other types of psoriasis.

Duration and Progression

An outbreak of guttate psoriasis typically lasts several weeks to a few months. Often, the lesions resolve on their own. 

However, guttate psoriasis may recur, especially if the underlying trigger is not managed. Guttate psoriasis can also progress into chronic plaque psoriasis.

Diagnosis of Guttate Psoriasis

People struggling with symptoms of guttate psoriasis should consult their doctor for a thorough medical assessment. Prior to the visit, it is helpful to note a personal or family history of psoriasis, and to record skin symptoms and any recent infections. 

Guttate psoriasis diagnosis is primarily clinical. A primary care provider can diagnose and manage mild to moderate plaque psoriasis, although a dermatologist is an expert at diagnosing and treating psoriasis.

Clinical Evaluation

Your healthcare provider will take a detailed medical history including asking about your symptoms, family history, and potential triggers such as stress, injuries, or medications. 

They will also inquire about a personal or family history of psoriasis, as well as any recent infections. Lifestyle factors like diet, exercise, alcohol use, and smoking will also be discussed.

Physical Examination

The doctor will check your vital signs and conduct a thorough exam of your skin, scalp, and nails. Your joints may also be assessed. 

Laboratory Tests

A skin biopsy is generally not needed for typical psoriasis cases, but this may be performed for atypical presentations or diagnostic uncertainty to distinguish psoriasis from other skin conditions.

A throat or perianal swab may be performed and cultured if there is suspicion of an active streptococcal infection. This can help confirm the diagnosis of guttate psoriasis. 

Differential Diagnosis

To properly diagnose guttate psoriasis, ruling out similar-looking conditions is important. Conditions to consider include: 

Tinea Corporis (Ringworm): fungal infection presenting with red, scaly, ring-shaped patches. A KOH test can confirm fungal elements.

‍Secondary Syphilis: secondary syphilis presents with a widespread rash that often involves the palms and soles, accompanied by flu-like symptoms. It can be mistaken for guttate psoriasis due to the presence of scaly, red patches on the skin.

Nummular Eczema: nummular eczema is characterized by round, coin-shaped patches of itchy, scaly, and inflamed skin, often on the limbs. It can resemble guttate psoriasis because both conditions feature red, scaly lesions that can occur after skin injuries or infections.

Pityriasis Rosea: pityriasis rosea begins with a large "herald patch" followed by a rash of smaller, oval-shaped pink patches that align with skin lines. It is similar to guttate psoriasis in appearance due to the small, scaly, red lesions that can develop across the trunk and limbs.

Treatment Options for Guttate Psoriasis

Topical treatments, and sometimes phototherapy, may be considered as first-line treatments. Guttate psoriasis can also resolve on its own.

Topical Treatments

For mild to moderate guttate psoriasis, corticosteroid, vitamin D analog, and coal tar creams and shampoos reduce inflammation, itching, and skin cell turnover.

Phototherapy 

UV light therapy, particularly narrowband UVB (NB-UVB), slows skin cell growth and is effective for widespread psoriasis, especially when topical treatments fail, with fewer systemic side effects.

Systemic Treatments

For severe cases, systemic medications may be used but they have not been extensively studied for guttate psoriasis. 

Traditional medications like methotrexate, cyclosporine, and acitretin may be used, while biologics such as TNF-α inhibitors, IL-23 inhibitors, and IL-17 inhibitors target specific immune responses and are administered via injection or infusion.

When necessary, treating the underlying infections with antibiotics or appropriate medications may be considered..

Lifestyle Modifications

Stress reduction, exercise, a healthy diet, weight management, and avoiding triggers like smoking and alcohol can help manage symptoms.

Home Remedies

Regular moisturizing, sun exposure, and therapies like topical aloe vera, apple cider vinegar, acupuncture, and turmeric supplements may reduce flare-ups and manage symptoms.

Managing and Preventing Guttate Psoriasis Outbreaks

Managing and preventing guttate psoriasis is important to reduce a person’s likelihood of developing chronic plaque psoriasis. 

Monitoring and Managing Infections

It’s important to seek early treatment of streptococcal throat infections and other bacterial infections to prevent the onset or worsening of guttate psoriasis. This is especially true in patients who already have plaque psoriasis. 

Prompt diagnosis and antibiotic treatment can help reduce the risk of flare-ups and maintain better control of the skin condition.

Stress Management 

Stress is a known trigger for guttate psoriasis, so implementing stress-reduction strategies such as mindfulness, regular exercise, meditation, and adequate sleep can help manage symptoms and reduce the frequency and severity of outbreaks.

Long-Term Skin Care

Maintaining healthy skin is essential in preventing psoriasis flare-ups. Use gentle, fragrance-free moisturizers and cleansers to keep the skin hydrated and avoid irritation. Regular moisturizing helps to soothe the skin and reduce scaling and itching associated with guttate psoriasis.

Regular Follow-Up with Healthcare Providers

Ongoing care and monitoring by healthcare professionals are important, particularly for people with recurrent or severe guttate psoriasis. Regular check-ups help manage symptoms, adjust treatments, and monitor for any complications, ensuring optimal long-term management of the condition.

Coping with the Emotional Impact

Guttate psoriasis can leave people feeling uncomfortable in their skin. Visible lesions can have psychological impacts including feelings of self-consciousness, low self-esteem, and social anxiety. It's important to acknowledge these emotional challenges and seek mental health support if needed, to improve overall well-being and quality of life.

Building a Support System

Connecting with support groups, either in-person or online, can provide valuable emotional support, encouragement, and a sense of community. 

Sharing experiences with others who understand the challenges of living with guttate psoriasis can help reduce feelings of isolation and provide practical coping strategies.

Staying Informed and Educated

Staying educated about guttate psoriasis including understanding the condition, identifying your triggers, and discussing the latest treatment options with your doctor empowers you to manage your symptoms more effectively. 

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Key Takeaways

• Guttate psoriasis, often triggered by infections like strep throat, presents as small, drop-like lesions on the skin. It can be self-resolving, or in some cases it can progress to chronic plaque psoriasis. Treatment options include topical corticosteroids, phototherapy, and systemic medications for severe cases.

• With timely and proper treatment, guttate psoriasis can be effectively managed, helping to reduce symptoms, prevent progression to plaque psoriasis, and improve quality of life.

• Patients with guttate psoriasis should work closely with healthcare providers to develop and adjust a personalized treatment plan, ensuring optimal management and care.